Total Force Tricare

Washington struggles to define the right health care program for the Guard and Reserve.

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When the war on terror began Sept. 11, 2001, America suddenly understood how reliant the nation had become on the Guard and Reserve—for security at home and to take the fight overseas. Both Administration officials and lawmakers call the reserves indispensable to the Total Force.

Last year, Congressman John M. McHugh (R-N.Y.), a member of the House Armed Services Committee, noted that Guard and Reserve support for peacetime military operations has “grown 12-fold to the annual equivalent of 33,000 active duty personnel.” He went on to say that the Global War on Terror has brought additional large and short-notice call-ups. Some 40 percent of the US troops covering operations in Iraq now are Guardsmen and Reservists.

The Pentagon knows it cannot go to war without these components. However, officials point out that claims of repeated, wholesale mobilizations are not valid. Since 9/11, DOD has mobilized only about 36 percent of its nearly 900,000 selected reserves, Defense Secretary Donald H. Rumsfeld told lawmakers in February.

Nonetheless, lawmakers, since 2001, have introduced more than two dozen bills covering health care, income loss protection, and other efforts to aid reservists.

For a third straight year, Congress has expanded health care benefits for Guard and Reserve personnel and their families. The latest benefit package included a $400 million spending cap and an end date of Dec. 31, 2004. Lawmakers had planned a more sweeping change but met resistance from the Administration, which worried about the cost.

A bipartisan group of lawmakers wanted to offer non-activated reservists and their families the same access to health care benefits that is provided to active duty personnel and their families. The Senate, in May 2003, overwhelmingly endorsed the plan. Rumsfeld told lawmakers that it would be hugely expensive and would take money from other important military programs. Others countered that the cost would be far more reasonable, with reservists paying a share of the cost, and called providing expanded Tricare access a matter of “fairness.”

At their urging, Senate Minority Leader Tom Daschle (D-S.D.) and Sen. Lindsey Graham (R-S.C.), who were the lead sponsors on last year’s legislation to extend Tricare to all non-activated reservists, have reintroduced that measure for 2005.

A key concern for Daschle and Graham, as well as many other lawmakers, is that some 20 percent of today’s reserve forces have no health insurance. (Daschle estimates that the number is closer to 30 percent, at least in South Dakota.) They also focus on the fact that reserves are more integrated into military operations than ever before.

“If you’re doing the same job,” Daschle said at a March 4 Senate hearing, “you ought to have the same access to benefits.” However, he emphasized, that the Daschle/Graham legislation doesn’t offer a “free handout;” instead the non-activated reservists would pay a premium for their Tricare coverage.

Graham, who is an Air Force Reservist, testified at the same hearing that their bill is “about recruiting, retention, and readiness.” He said, “The one thing I have learned, from Desert Storm to now, is that if we do not do better with the [reserve] benefit package, we’re going to lose a lot of dedicated, patriotic people because the stress on their families is immense.”

Readiness is at issue, continued Graham, because 25 percent of the Guard and Reserve troops called to active duty are unable to be deployed because of health problems, primarily dental.

The Pentagon, conversely, does not view the expansion of Tricare coverage as a means to “leverage readiness,” said Charles S. Abell, principal deputy undersecretary of defense for personnel and readiness.

Both Abell and the Pentagon’s top health care official, William Winkenwerder Jr., testifying on March 4, said that ensuring medical readiness of activated reservists is a high priority, but they were not certain that the expanded health care benefit would solve the problem.

Abell told Senators, “Tricare for non-active reservists and their families could have a long-term fixed cost of $1 billion annually with little payoff in readiness.”

Winkenwerder suggested carefully reviewing the proposal and conducting a “limited demonstration” to determine feasibility and test assumptions about any “beneficial impact.”

For a change, the Congressional watchdog agency, the General Accounting Office, may agree with DOD. In a September 2003 report on reserve health care issues, the GAO said it had a “number of concerns.”

GAO noted that DOD says it does not have an overall recruiting and retention problem in the reserves and that it’s too early to tell whether there will be a problem. The GAO also said that most reservists activated prior to 2001—90 percent, according to a 2002 DOD survey—retained their civilian health insurance. It raised the issue of possible anger within the active force if the reserve force gains the same benefits. And the GAO expressed concern about DOD’s rising health care costs—“the fastest growing category of operation and support spending.”

The GAO summarized its position: “While proponents have cited a number of reasons for this legislation, concerns have also been raised. We believe these concerns may outweigh the perceived benefits and costs of the legislation.” However, it also said that DOD doesn’t have sufficient information to determine the need for expanded benefits or the impact on the military health care system.

Congress has directed the GAO to conduct a comprehensive assessment of the health care needs of reservists by May 1.

The Compromise

Meanwhile, the compromise deal worked out last year between Congress and the Administration opened the door for expanded benefits to some 170,000 reservists and their families without private health insurance. If they decide to sign up for Tricare, they will have to pay premiums, which will be 28 percent of program costs or roughly $420 a year per individual or $1,440 for family, plus the usual co-payments and deductibles.

The compromise package of initiatives, called the 2004 Temporary Reserve Health Benefit Program (TRHBP), was included in the defense emergency supplemental legislation. Despite the work of a special task force set up before the law was signed, implementation has been difficult.

The $400 million spending cap imposed by Congress added to the difficulties. Tricare officials had to devise a system to keep real-time tabs of dollars spent, as well as to issue rules and modify existing contracts, all of which left reservists and their families waiting months to take advantage of new pre- and post-mobilization benefits.

As of mid-February, more than three months after the law was signed, most of the benefits still were not available to reserve families. The Pentagon announced Feb. 12 that the 2004 benefits would be implemented in stages throughout the spring.

One of the biggest challenges, said Rear Adm. Richard A. Mayo, deputy director for the Tricare Management Activity, has been delays in modifying the Defense Enrollment Eligibility Reporting System (DEERS). Tricare relies upon DEERS to verify that beneficiaries are properly enrolled and eligible for health benefits. The enrollment system had to be reprogrammed to recognize several new benefits and to identify as eligible many thousands of individual reservists and their families. Modifying DEERS also was critical for tracking the cost of the initiatives.

Mayo said he expects uninsured drilling reservists to be able to enroll in Tricare by year’s end, if the $400 million hasn’t already been spent. That money also must cover the cost of reprogramming DEERS, modifying Tricare support contracts, and marketing for reserve enrollment.

The New Benefits

In the 2004 TRHBP package, Congress authorized three temporary benefits that run from Nov. 6, 2003, through Dec. 31:

One provision extends temporary eligibility to Tricare for reservists and their family members if the reservist is either unemployed or employed but not eligible for employer-sponsored health coverage.

A second provision temporarily established an earlier eligibility date for Tricare medical and dental coverage. Eligibility begins on the day the reservist receives “delayed-effective-date” active duty orders or 90 days prior to the start of the active duty period, whichever is later. Family members are covered if the mobilization is to last longer than 30 days. Before this change, reservists became eligible for Tricare only when actually on active duty.

The third temporary provision lengthens Tricare eligibility for certain reservists from 60 or 120 days to 180 days under the Transitional Assistance Management Program. This longer coverage applies to those deactivated or separated from service after Nov. 6, 2003.

Pentagon health officials urged Guard and Reserve members and their families to save health care receipts, claims, and explanation of benefits for the term of the temporary legislation.

The 2004 program also included three permanent benefits:

One calls for the Pentagon to provide medical and dental screening and care for Individual Ready Reservists who are alerted for mobilization. Reservists previously had to be on active duty to be screened and receive care.

A second provision makes newly commissioned officers eligible for Tricare, pending their orders to active duty—if the officer lacks other health care coverage.

The third requires the reserve components to appoint health care benefits counselors to assist reservists. There is to be at least one counselor who is expert on reserve health benefits assigned to every Tricare region.

This is one change that received enthusiastic support from DOD officials. “Most of our beneficiary counselors are familiar with the Tricare benefit as it exists day to day,” said Mayo, adding that the reserve benefit is different. “We need to have a specialist thoroughly familiar with not only current but new provisions of the reserve benefit.”

What’s Next?

The Congressional efforts to boost reserve health benefits last year took on added importance in October 2003 after a UPI news service article reported that hundreds of Guardsmen and Reservists—most medically unfit when called up, but some sick or wounded and recovering from tours in Iraq—were stuck in “medical hold” at Ft. Stewart, Ga. They had languished for weeks or months, living in rundown barracks, while they waited for medical care.

The Army confirmed a shortage of medical staff and adequate housing. It immediately sent more reserve soldiers to civilian providers and found better accommodations.

David S.C. Chu, undersecretary of defense for personnel and readiness, revised policy to improve treatment of reservists in medical hold. The new rules require specialty care within two weeks vs. the Tricare standard of 30 days.

If such care isn’t available on base, the applicable military treatment facility must refer the reservists promptly to other military, VA, or civilian physicians. And medical-hold reservists are to be billeted in the same quality housing as active duty members.

On the whole, Pentagon officials say they want more time to evaluate the question of what benefits should be provided to reservists, particularly as they relate to non-activated reservists. Abell calls the latter issue “a more difficult question.”

Extending health care benefits to reservists who are not mobilized, or even alerted for mobilization, said Abell, is a “complex benefit package.” He continued, “It’s complex to administer, and it’s complex to discover what are the driving factors that influence the [reservists’] behavior.”

Abell said the Pentagon would like to run a demonstration project for a couple of years that would let it “measure the outcomes and the expenses and the return on investment.”

Meanwhile, discounts on Tricare coverage for the families of activated reservists that were enacted soon after the 9/11 attacks also are due to expire in 2004 unless Congress votes to extend them again or make them permanent.

Other Recent Tricare Benefits

Overall, reservists and their families have seen military health benefits improve in the last three years. Here’s a rundown of changes since the war on terrorism began, exclusive of reforms adopted late last year.

Tricare Reserve Family Demonstration Project. This program, which is designed to ensure continuity of care and timely access to the military health system for family members of hundreds of thousands of reservists, was implemented Sept. 14, 2001, and was to end Oct. 31, 2003, however, DOD extended it for another year.

Participation in the project is open to families of reservists activated for 30 days or longer. They are eligible for Tricare’s triple option: Prime (enrolled managed care), Extra (preferred provider networks), or Standard (traditional fee-for-service insurance). (Prime eligibility before March 10, 2003, was limited to family members of reservists who had been activated for 179 days or longer.)

Two enhancements reduced out-of-pocket expenses for reserve families. Participants do not have to pay the annual deductible of up to $300 for Tricare Extra and Standard. They are responsible for a 20 percent co-payment under Standard and 15 percent co-payment under Extra. And DOD covers costs for civilian providers that exceed the Tricare Maximum Allowable Charge—up to 115 percent of the TMAC rate—less applicable co-payment.

Like active duty family members, those using Tricare Standard do not have to obtain a nonavailability statement before receiving nonemergency inpatient care if they reside within 40 miles of a military treatment facility.

Reserve Dental Program. Since early 2001, drilling reservists and members of the non-drilling Individual Ready Reserve have been able to enroll in a reserve dental program if they had at least 12 months remaining on their service commitment.

Activated reservists are removed automatically from the reserve dental program and become eligible for military care. Family members of a non-activated reservist enrolled in the program may participate, but the premium they pay is more than twice as much as that paid by active duty family members. The monthly premium level falls to the active duty family member rate once a reservist is activated.

Tricare Prime Remote. In March 2003, family members of reservists activated for more than 30 days became eligible to enroll in the Tricare Prime Remote for Active Duty Family Members program if they live at least 50 miles or more from the nearest military treatment facility. The remote program provides health care coverage through civilian health care providers.

The legislation creating this eligibility stated the family member must “reside with” the activated reservist. According to the Pentagon, DOD interprets that to mean “eligible family members resided with the service member before the service member left for their home station, mobilization site, or deployment location, and the family member continues to reside there.”

Tom Philpott is a contributing editor of Air Force Magazine. He is the editor of “Military Update” and lives in the Washington, D.C., area. His most recent article for Air Force Magazine was “The VA’s Big Makeover,” in the January issue.